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1295621076 NPI number — TIDEWATER DENTAL STUDIO PLLC

NPI Number: 1295621076
Health Care Provider/Practitioner: TIDEWATER DENTAL STUDIO PLLC

Information about “1295621076” NPI (TIDEWATER DENTAL STUDIO PLLC) exists in 1295621076 in HTML format HTML  |  1295621076 in plain Text format TXT  |  1295621076 in PDF (Portable Document Format) PDF  |  1295621076 in an XML format XML  formats.

NPI Number : 1295621076 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1295621076",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "TIDEWATER DENTAL STUDIO PLLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "4867 BAXTER RD STE 101",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "VIRGINIA BEACH",
    "MailingAddressStateName": "VA",
    "MailingAddressPostalCode": "23462-4469",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "757-499-8139",
    "MailingAddressFaxNumber": "757-473-8816",
    "FirstLinePracticeLocationAddress": "4867 BAXTER RD STE 101",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "VIRGINIA BEACH",
    "PracticeLocationAddressStateName": "VA",
    "PracticeLocationAddressPostalCode": "23462-4469",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "757-499-8139",
    "PracticeLocationAddressFaxNumber": "757-473-8816",
    "EnumerationDate": "06/17/2025",
    "LastUpdateDate": "06/17/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "ACOSTA-SASSOON",
    "AuthorizedOfficialFirstName": "JOANNA MARIE",
    "AuthorizedOfficialMiddleName": "S.",
    "AuthorizedOfficialTitle": "OWNER",
    "AuthorizedOfficialNamePrefix": "DR.",
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "DDS",
    "AuthorizedOfficialTelephoneNumber": "757-499-8139",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "261QD0000X",
        "TaxonomyName": "Dental Clinic/Center",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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